While it is common to describe medical organizations as parallel silos of clinical and business activity, I continue to believe a better mental model is a three part system. Every clinical entity has to avoid failing in three dimensions. First, of course, is financial failure. The second is clinical failure—not meeting the standard of care for patients. The third is failing to care for the people who have to provide the care—burnout and staff turnover. Of the three, financial failure is easiest to define. One retired medical director friend of mine used to say the ultimate disservice to our patients was to go bankrupt. Clinical failure is sometimes less clear, although death and inadvertent injury are certainly good examples. (Clinical success, though, is more than the absence of failure and presently we don’t have very many robust measures of success.) Burnout and staff turnover are getting a lot of press, but I don’t get the sense there is much effective effort being directed toward addressing the dynamic linkage between this and the other two measures of failure. In a conversation with my hospital CEO about these issues he commented: “We know we are in the ditch when we are there, but we don’t seem to be able to recognize we are going into the ditch before it happens.” His honesty illustrates the management dilemma—how can we monitor this? And if we spot it, can we do effective systemic interventions? As a possible answer, Hellwig and associates have published an article called “An Early Warning System for Your Team’s Stress Level.”[1] They cite a recent study from the UK identifying workload pressure and lack of managerial support as the main factors listed by employees as sources of work-related stress.

“This raises a long-recognized conundrum: pressure to perform is effective to a certain, unpredictable degree. Positive stress, known as ‘eustress,’ helps keep people energized and alert. However, the boundary between eustress and distress—harmful stress—can be crossed quickly, catching managers and employees unprepared. Everyone has a tipping point—influenced by physiological as well as psychological factors—when stress or pressure leads to decreasing performance, and if not addressed, eventually to burnout.”

They proposed an Apgar score, based on the effectiveness of the Apgar score in evaluating newborn babies to identify those who may be in distress. The original Apgar score was an acronym based on the name of the person who described it—Dr. Virginia Apgar. In her honor Hellwig and colleagues have kept the acronym, but given it new definitions, which I am quoting verbatim here.

A=Appearance. How does the person look? Does he/she seem overly tired? Has he/she been losing or gaining weight? Is there any indication of substance abuse?P=Performance A decrease in performance, particularly over time, may be linked to increasing distress. On the other hand, a force effort to over-perform—becoming a workaholic—is also a warning sign.

G=Growth Tension Growth is the result of learning and stretch goals. Everyone is different; some people take to new challenges easily, whereas others may find them more difficult. Is the person becoming bored? Or conversely, does the person seem overwhelmed?

A=Affect Control “Affect” is another word for emotion. Everyone has good days and bad days, but most people can regulate their emotions in a way that is appropriate for the workplace. However, noticeable and lasting changes in emotional state—including emotional outbursts or high and low mood swings—can be related to an overload of physical and psychological pressure.

R=Relationships Personal relationships are an essential part of mental health. In situations of increased stress, it is possible to observe deterioration in the quality of relationships at work, including social isolation.

As in the original Apgar score, they suggest a 10 point scale with two points for each item. On the other hand, you could just ask the person to rate themselves, saving observer ratings for situations where the person was resistant to participating. For people like my hospital CEO, a number might be more useful. Perhaps each of his direct reports could make a weekly or monthly survey of their direct reports and generate an “Stress Index.” If carried through the organization, real-time information might be gleaned.

“Our hope is that the Stress-APGAR could become a starting point for courageous conversations on how to create better places to work. From a sustainability perspective, it’s essential to create work environments where cases of stress imbalance are made discussable. And as Hans Selye, the father of modern stress research once said, ‘It is not stress that kills us, it is our reaction to it.’”

If we are going to really improve our hospitals and our clinics, we have to pay attention to this objective as well as making money and meeting clinical expectations. Not an easy task, and not one with a simple, cookbook answer. But the lack of a simple answer does not gainsay the importance of the task.

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